MEDICAL INSPECTION 



SUGGESTIONS TO TEACHERS 
AND SCHOOL PHYSICIANS 




ISSUED BY THE 

Massachusetts Board of Education 



SUGGESTIONS 



TO 



Teachers id School Physicians 



REGARDING 



Medical Inspection. 



Issued by the 
Massachusetts Board of Education. 




BOSTON : 

WRIGHT & POTTER PRINTING CO., STATE PRINTERS, 

18 Post Office Square. 

1907. 






■MAY 23 1907 
D. OF D. 



Ctfmmtfttbttalfjj Qi IJassaxfrnssttS; 



State House, Boston, Jan. 23, 1907. 

In order to render the medical inspection re- 
quired by chapter 502, Acts of 1906, effective 
and uniform throughout the State, His Excel- 
lency Governor Guild appointed a committee to 
prepare a circular of advice to the school physi- 
cians of the State. 

This committee consisted of Dr. Henry P. 
Walcott, Dr. Charles Harrington ond Dr. Julian 
A. Mead, representing the State Board of 
Health; Mrs. Ella Lyman Cabot, Mr. George 
I. Aldrich and Mr. George H. Martin, repre- 
senting the Board of Education ; and Dr. Robert 
W. Lovett, Dr. Harold Williams and Dr. W. 
H. Devine, representing the medical profession. 

A sub-committee of this body arranged for 
conferences with the heads of departments and 
others connected with the medical schools and 
hospitals in and about Boston, and with physi- 
cians who have had experience in school inspec- 
tion. These gentlemen have given freely of 
their time and thought, and have furnished to 
the committee the suggestions contained in this 
circular. 



These suggestions cover the ground included 
in the clause in section 5 of the law : " The 
school committee of every city and town shall 
cause every child in the public schools to be 
separately and carefully tested and examined at 
least once in every school year, to ascertain 
whether he is suffering from defective sight or 
hearing, or from any other disability or defect 
tending to prevent his receiving the full benefit 
of his school work, or requiring a modification 
of the school work in order to prevent injury 
to the child or to secure the best educational 
results." 

The Board of Education issues this circular 
in the assurance that it represents the highest 
professional authority in the specialties covered 
by the law, and commends it to the careful at- 
tention of all teachers, school physicians and 
other school officers. 

The following are the subjects treated, with 
the names of the physicians who have con- 
tributed suggestions : — 

1. Infectious Diseases. — Dr. John H. McCol- 
lom. 

2. The Eye. — Dr. Myles Standish, Dr. Henry 
B. Chandler, Dr. Charles H. Williams, Dr. David 
W. Wells. 

3. The Ear. — Dr. Clarence J. Blake, Dr. D. 
Harold Walker. 

4. The Throat and Nose. — Dr. Samuel W. 



Langrnaid, Dr. Algernon Coolidge, Jr., Dr. 
Frederic C. Cobb, Dr. George B. Rice. 

5. The Skin. — Dr. John T. Bowen, Dr. James 
S. Howe, Dr. George F. Harding, Dr. Charles 
J. White, Dr. C. Morton Smith, Dr. John L. 
Coffin. 

6. Diseases of Bones and Joints. — Dr. Ed- 
ward H. Bradford, Dr. Augustus Thorndike, 
Dr. Charles F. Painter, Dr. George H. Earl, Dr. 
Robert Soutter. 

7. Children's Diseases. — Dr. Thomas M.' 
Rotch, Dr. John L. Morse, Dr. John H. Moore, 
Dr. Robert W. Hastings, Dr. Edmund C. 
Stowell. 

8. The Teeth. — Br. Edward W. Branigan, 
Dr. George A. Bates, Dr. Eugene H. Smith, Dr. 
Samuel A. Hopkins. 

9. Nervous Diseases. — Dr. James J. Putnam, 
Dr. George L. Walton, Dr. Morton Prince, Dr. 
William N. Bullard, Dr. Edward W. Taylor, 
Dr. John J. Thomas, Dr. Walter E. Fernald. 

10. School Hygiene. — Dr. Henry J. Barnes. 

11. School Furniture. — Dr. Frederick J. Cot- 
ton, Mr. R. Clipston Sturgis. 

12. School Inspectors. — Dr. George S. C. 
Badger, Dr. H. Lincoln Chase, Dr. Harry M. 
Cutts. 

GEORGE H. MARTIN, 

Secretary. 



DISEASES. 



Infectious Diseases. 

Diphtheria. — It is a well-recognized fact that 
nasal diphtheria of a mild type without consti- 
tutional disturbance is one of the most impor- 
tant factors in causing the spread of the disease, 
and also that children very frequently have pro- 
fuse discharges from the nose. It therefore 
follows that, in order properly to inspect the 
public schools, it is important that cultures 
should be taken from the nose in every case 
where there is a persistent discharge, particu- 
larly if there is any excoriation about the nos- 
trils. 

The throat should be examined at varying 
intervals, depending upon the physical condi- 
tion of the children. Any hoarseness or any 
thickness of the voice should cause an examina- 
tion of the throat. If the tonsils are enlarged, 
if the mucous membrane is congested, if there 
is swelling of the palate, a culture should be 
taken. These symptoms precede diphtheria. 

A child with positive cultures should be ex- 
cluded from school until two consecutive nega- 
tive cultures at an interval of forty-eight hours 
have been obtained. 



Scarlet Fever. — If there is a sudden attack 
of vomiting', if there is any redness of the 
throat, if the child complains of headache, if 
there is an unexplained rise in temperature, the 
child should be isolated at once. Any desquama- 
tion (peeling of the skin) should be looked 
upon with suspicion. If there are any breaks 
at the finger tips, if on pressing the pulp of the 
finger there is a white line at the juncture of 
the nail with the pulp of the finger, particularly 
if this occurs in the majority of the finger tips, 
the child should be excluded from the school. 

A child who has had scarlet fever should not 
return to school until the process of desquama- 
tion has been entirely completed, and all dis- 
charge from the nose and ears has ceased. 

Measles. — Running from the nose and slight 
intolerance of light may call for an examination 
of the mucous membrane of the mouth for Kop- 
lik's sign. Koplik's sign, so called, is the pres- 
ence on the lining membrane of the mouth, near 
the molar teeth, of minute pearly white blisters, 
without any inflammation around them. There 
may be only two or three of these blisters, and 
they may easily escape detection if the patient 
is not carefully examined in a good light. These 
blisters are certain forerunners of an attack of 
measles. 

No child should return to school after an at- 
tack of measles until the desquamation is en- 



8 



tirely completed, and the child has recovered 
from the intercurrent bronchitis. 

Mumps. — Any swelling or tenderness in the 
region of the parotid glands (situated behind 
the angle of the jaw) should be looked upon 
with suspicion. It is important to notice any 
enlargement or swelling about Steno's duct (in- 
side the mouth, opposite the second upper molar 
tooth), as this is a very frequent symptom of 
mumps. 

A child should be excluded from school until 
one week has elapsed after the disappearance 
of all swelling and tenderness in the region of 
the parotid glands. 

Whooping-cough. — A persistent paroxysmal 
cough, frequently accompanied with vomiting, 
no matter whether there is any distinct whoop 
or not, is indicative of whooping-cough. In 
cases of whooping-cough of long standing, even 
if there has been no distinct whoop, an ulcer 
on the band connecting the lower surface of the 
tongue with the floor of the mouth is found in 
a certain number of cases. If there is no dis- 
tinct ulceration, there may be a marked conges- 
tion of the band. 

As long as there is any cough, the child who 
has had whooping-cough should be looked upon 
with suspicion. 

Varicella {Chicken Pox). — A few black 
crusts scattered over the body are evidences of 
an attack of chicken pox. The crusting seen in 



impetigo must be differentiated from that of 
chicken pox. 1 

No child should return to school until all 
crusts have disappeared from the body, particu- 
larly from the scalp, for in this region the 
crusts remain longer than elsewhere. 

The Eyes. 

[Supplement to circular already issued.] 

There are certain children who show normal 
vision by the ordinary tests, yet whose parents 
should be notified to have the eyes examined. 
These are: (1) children who habitually hold the 
head too near the book (less than twelve to 
fourteen inches) ; (2) children who frequently 
complain of headache, especially in the latter 
portion of school hours; (3) children in whom 
one eye deviates even temporarily from the 
normal position. 

It should be remembered that the following 
symptoms are at times indicative of trouble 
with the eyes: (1) habitual scowling and wrink- 
ling of the forehead when reading or writing; 
(2) twitching of the face; (3) inattention and 
slowness in book studies in a child otherwise 
bright. 

The Ears. 
See circular of directions for testing hearing, 
already in hands of teachers. 

1 See Diseases of the Skin. 



10 



The Throat and Nose. 

In all cases of acute illness the throat should 
be examined for the presence of the eruption 
of scarlet fever and measles and for the exuda- 
tion or membrane of tonsilitis and diphtheria, 
and a culture taken in any suspected case of the 
latter. 

The presence of discharge from the nose 
should be noted, and if it is thick and creamy, 
a culture should always be taken. In all cases 
of severe hoarseness, with difficult breathing, 
diphtheria should be suspected. If the dis- 
charge from the nose is only from one nostril, a 
foreign body in the nose should be looked for. 

In cases of chronic nasal obstruction, as 
evinced by mouth-breathing, snoring, continual 
post-nasal catarrh or recurring ear trouble, the 
presence of an adenoid growth (third tonsil) 
should be suspected, and the child referred for 
special examination and treatment. As a rule, 
digital examination for adenoids should be made 
only by the operating surgeon. Obviously large 
tonsils, recurring tonsilitis and enlargement of 
the glands of the neck, suggest the advisability 
of referring the child to the family physician 
as to the propriety of removing the tonsils. 

Recurring nose-bleed should be referred for 
special treatment. 

In cases of eczema about the nostrils, a cause 
may be sought in pediculi capitis (head lice). 



11 



In referring* eases for treatment, school phy- 
sicians, in addition to the diagnosis, should 
state the symptoms upon which the diagnosis 
is based, for the henefit of the family physician 
or specialist. 

Diseases of the Skin. 

Scabies (the Itch). — A contagious skin dis- 
ease, due to an animal parasite which burrows 
in the skin, causing intense itching and scratch- 
ing. The disease usually begins upon the hands 
and arms, spreading over the whole body, but 
does not affect the face and scalp. Between the 
fingers, on the front of the wrist, at the bend 
of the elbows and near the arm pits are favorite 
locations for the disease; but in persons of 
cleanly habits the disease may not show at all 
upon the hands, and its real nature is deter- 
mined only after a most thorough and careful 
examination. There is a great variation in the 
extent and severity of this disease, lack of per- 
sonal care and cleanliness always favoring its 
development. Scratching soon brings about an 
infection of the skin with some of the pus- 
producing germs, and the disease is then accom- 
panied by impetigo, or a pus infection of the 
skin. 

At the present time itch is very common and 
widespread, and, because of the great varia- 
tion in its severity, mild cases have been mis- 
taken for hives, eczema, etc., the real condition 



12 



not being recognized, and the disease spread in 
consequence. All children who are scratching 
or have an irritation upon the skin should be 
examined for scabies. 

It is very important that all infected members 
of a family be treated till cured, else the disease 
is passed back and forth from one to another. 
It is also important that all underclothing, bed- 
ding, towels, etc., things that come in contact 
with the body, be boiled when washed. 

All cases of scabies should be excluded from 
school until cured. 

Pediculi Capitis (Head Lice). — An extremely 
common accident among children, either from 
wearing each others' hats and caps, or hanging 
them on each others' pegs, or from combs and 
brushes. No person should be blamed for hav- 
ing lice, — only for keeping them. 

The irritation caused by vermin in the scalp 
leads to scratching, which in turn causes an in- 
flammation of the skin of the neck and scalp. 
The skin then easily becomes infected with some 
of the pus-producing germs, and large or small 
scabs and crusts are formed from the dried 
matter and blood. Along with this condition 
the glands back of the ears and in the neck be- 
come swollen, and may be very painful and 
tender. 

The condition of pediculosis is most easily 
detected by looking for the eggs (nits), which 



13 



are always stuck onto the hair, and are not 
readily brushed off. The condition is best 
treated by killing the living parasites with crude 
petroleum, and then getting rid of the nits. 
With boys, this is easy, — a close hair cut is all 
that is needed; with girls, by using a fine- 
toothed comb wet in alcohol or vinegar, which 
dissolves the attachment of the eggs to the hair. 
All combs and brushes must be carefully 
cleansed. 

Children with pediculosis should be excluded 
from school until their heads are clean. By 
chapter 383, Acts of 1906, parents who neglect 
or refuse to care for their children in this re- 
spect may be prosecuted under the compulsory 
attendance law. 

Bingworm. — A vegetable parasitic disease of 
the skin and scalp. When it occurs upon the 
skin, it yields readily to treatment; but upon 
the scalp it is extremely chronic. Ringworm of 
the skin usually appears on the face, hands or 
arms, — rarely upon the body, — in varying 
sized more or less perfect circles. One or more, 
usually not widely separated, may be present 
at the same time. All ringed eruptions upon 
the skin should be examined for ringworm. 

When the disease attacks the scalp, the hairs 
fall or break off near the scalp, leaving dime 
to dollar sized areas nearly bald. The scalp in 
these areas is usually dry and somewhat scaly, 



14 



but may be swollen and crusted. The disease 
spreads at the circumference of the area, and 
new areas arise from scratching, etc. 

Another disease, somewhat like ringworm of 
the scalp, is known as f avus, — a disease much 
more common in Europe than America. In this 
disease quite abundant crusts of a yellowish 
color are present where the process is active. 
The roots of the hairs are killed, so that the 
loss of hair from this disease is permanent, a 
scar remaining when the condition is cured. 

Care must be taken to see that all combs and 
brushes are thoroughly cleansed, and to prevent 
children wearing each others' hats, caps, etc. 

Children with ringworm should not be al- 
lowed to attend school. 

Impetigo. — A disease characterized by few 
or many large or small flat or elevated pustules 
or festers upon the skin. The condition is often 
secondary to irritation or itching diseases of 
the skin (hives, lice, itch), and scratching starts 
up a pus infection. 

The disease most often appears upon the face, 
neck and hands; less often upon the body and 
scalp. The size of the spots varies very much, 
and they often run together to form on the face 
large superficial sores, covered with thick, dirty, 
yellowish or brownish crusts. 

The disease is contagious, and often spread 
by towels and things handled. 



15 



Children having impetigo should not be al- 
lowed to attend school until all sores are healed 
and the skin is smooth. 

Diseases of the Bones and Joints. 

All noticeable lameness, whether sudden or 
continued, may indicate serious joint trouble, or 
may be due to improper shoes. These cases, as 
well as curvatures of the spine, as indicated by 
habitual faulty postures at the desk or in walk- 
ing, should be referred for medical inspection. 

Spinal curvature should be suspected when 
one shoulder is habitually raised or dropped, or 
when the child leans to the side, or shows per- 
sistent round shoulders. 

Complaints of persistent " growing pains " 
or " rheumatism " may be the earliest signs of 
serious disease of the joints. 

Some General Symptoms of Disease in Chil- 
dren which Teachers should notice, 
and on Account of which the Children 
should be referred to the School Physi- 
cian. 
Emaciation. — This is a manifestation of 
many chronic diseases, and may point especially 
to tuberculosis. 

Pallor. — Pallor usually indicates anaemia. 
Pallor in young girls usually means chlorosis, 



16 



— a form of anasmia peculiar to girls at about 
the age of puberty. It is usually associated 
with shortness of breath; the general condition 
otherwise usually appears good. Pallor may 
also be a manifestation of disease of the kid- 
neys; this is almost invariably the case if it is 
associated with puffiness of the face. 

Puffiness of the Face. — This, especially if it 
is about the eyes, points to disease of the kid- 
neys; it may, however, merely indicate nasal 
obstruction. 

Shortness of Breath. — Shortness of breath 
usually indicates disease of the heart or lungs. 
If it is associated with blueness, the trouble is 
usually in the heart. If it is associated with 
cough, the trouble is more likely to be in the 
lungs. 

Swellings in the Neck. — These may be due 
to mumps or enlargement of the glands. The 
swelling of mumps comes on acutely, and is 
located just behind, just in front and below the 
ear. Swollen glands are situated lower in the 
neck, or about the angle of the jaw. They may 
come on either acutely or slowly. If acutely, 
they mean some acute condition in the throat. 
If slowly, they are most often tubercular. They 
may also be the result of irritation of the scalp, 
or lice in the hair. 

General Lassitude, and Other Evidences of 
Sickness. — These hardly need description, but 



17 



may, of course, mean the presence or onset of 
any of the acute diseases. 

Flushing of the Face. — This very often 
means fever, and on this account should be 
reported. 

Eruptions of Any Sort. — All eruptions 
should be called to the attention of the physi- 
cian. It is especially important to notice erup- 
tions, because they may be the manifestations 
of some of the contagious diseases. The erup- 
tion of scarlet fever is of a bright scarlet color, 
and usually appears first on the neck and chest, 
spreading thence to the face. There is often 
a pale ring about the mouth in scarlet fever, 
which is very characteristic. There is usually 
a sore throat in connection with the eruption. 
The eruption of measles is a rose or purplish 
red, and is in blotches about the size of a pea. 
It appears first on the face, and is usually asso- 
ciated with running of the nose and eyes. The 
eruption of chicken pox appears first as small 
red pimples, which quickly become small blis- 
ters. 

A Cold in the Head, with Running Eyes. — 
This should be noticed, because it may indicate 
the onset of measles. 

Irritating Discharge from the Nose. — A thin, 
watery nasal discharge, which irritates the nos- 
trils and the upper lip, should always be re- 
garded with suspicion. It may mean nothing 



18 



more than a cold in the head, but not infre- 
quently indicates diphtheria. 

Evidences of Sore Throat. — Evidences of 
sore throat, such as swelling of the neck and 
difficulty in swallowing, are of importance. 
They may mean nothing but tonsilitis, but are 
not infrequently manifestations of diphtheria 
or scarlet fever. 

Coughs. — It is very important to notice 
whether children are coughing or not, and what 
is the character of the cough. In most cases, 
of course, the cough merely means a simple 
cold or slight bronchitis. A spasmodic cough, 
that is, a cough which occurs in paroxysms 
and is uncontrollable, very frequently indicates 
whooping-cough. A croupy cough, that is, a 
cough which is harsh and ringing, may indicate 
the disease diphtheria. A painful cough may 
indicate disease of the lungs, especially pleurisy 
or pneumonia. A long-continued cough may 
mean tuberculosis of the lungs. 

Vomiting. — Vomiting usually, of course, 
merely means some digestive upset. It may, 
however, be the initial symptom of many of 
the acute diseases, and is therefore of consider- 
able importance. 

Frequent Bequests to go out. — Teachers are 
too much inclined to think that frequent requests 
to go out merely indicate restlessness or per- 
versity. They often, however, indicate trouble 



19 



of some sort, which may be in the bowels, kid- 
neys or bladder; therefore, they should always 
be reported to the physician. 

The Teeth. 

Unclean mouths promote the growth of dis- 
ease germs, and cavities in the teeth are centers 
of infection. Pus from diseased teeth seriously 
interferes with digestion, and poisons the sys- 
tem. It causes a lowering of vitality, and ren- 
ders mental effort difficult. Diseased teeth, 
temporary as well as permanent, are frequently 
the cause of abscesses, and should be carefully 
watched and treated. 

Irregularities of the teeth, especially those 
which make it impossible to close the teeth 
properly, lead to faulty digestion, to mouth- 
breathing, and to other diseases and evils which 
an insufficient supply of oxygen produces. 

The first permanent molars are perhaps the 
most important teeth in the mouth, and are the 
most frequently neglected, because they are so 
often mistaken for temporary teeth. (It should 
be remembered that there are twenty temporary 
teeth, ten in each jaw, and that the teeth that 
come at about the sixth year immediately be- 
hind each last temporary tooth — four in all — 
are the first permanent molars.) 

The teacher should be on the lookout for pain 
or swelling in the face. When the child keeps 



20 



the mouth constantly open, an examination of 
the teeth should be made. When symptoms of 
indigestion occur, or physical weakness or men- 
tal dullness are observed, the teeth should be 
inspected. It should be remembered that dis- 
ease of the ears, disturbances of vision and 
swelling of the glands of- the neck may be 
caused by diseased teeth. 

It should be known that decay of the teeth 
is caused primarily by the fermentation of 
starchy foods and sugars, and that the greatest 
factor in preventing dental caries is the removal 
of food particles by frequent brushing. Chil- 
dren should be prevented from eating crackers 
and candy between meals, and when possible 
the teeth should be cleaned after eating. In- 
spection of the teeth by a dentist should be 
made at least once in six months. 

Nervous Troubles and Mental Defects. 

Teachers and medical inspectors of the schools 
should investigate children who show certain 
physical and mental symptoms. Especially 
should they take notice of the presence of these 
symptoms in a child who did not formerly show 
them. The most important of these are the 
following : — 

I. — Restlessness and inability to stand or sit 
quietly, in a previously quiet child, especially if 
to this is added irritability of temper and loss 



21 



of self-control, as shown by crying for trifles, 
or inability to keep the attention fixed. 

There may also be present quick, twitching 
movements of the muscles of the trunk, face, 
and especially of the hands, fingers, arms or 
legs. If severe, these may cause the child to 
drop things, render its work awkward, or inter- 
fere with buttoning the clothes, writing or draw- 
ing. Such children are often scolded for being 
inattentive or careless. 

These symptoms are the slighter ones of 
chorea (St. Vitus' Dance). With these should 
not be confounded other forms of twitching of 
muscles, such as the blinking of the eyelids, the 
slower twisting movements of the face or shoul- 
ders, or other parts of the body, often called 
habit spasms, which may be due to defects of 
vision, adenoid growths or other reflex causes. 
These latter cases do not usually need to be 
withdrawn from school work, though often re- 
quiring treatment ; while the former class should 
be removed from school at once, both for the 
child's sake, and to prevent an epidemic of 
imitative movements, such as sometimes occurs. 

II. — Another class of symptoms requiring 
investigation are repeated faintings especially 
if the child's lips become blue; attacks, often 
only momentary, in which the child stares fix- 
edly and does not reply to questions, or in which 
he suddenly stops speaking or whatever he is 



22 



doing, and is unaware of what is going on 
about him. These lapses of consciousness may 
be accompanied also by rolling up of the eyes, 
drooling, or unusual movements of the lips, and 
often appear like a " choking " attack. 

Sudden attacks of senseless movements of 
various sorts, such as twisting and pulling at 
the clothes or handkerchief, fumbling aimlessly 
at the desk, especially if there is no recollection 
afterwards of what was done, are often another 
expression of the same conditions. 

Such attacks, particularly if repeated at vary- 
ing intervals, even when not accompanied by 
complete loss of consciousness, are frequently 
as characteristic of epilepsy as the severe con- 
vulsions. 

Epileptic convulsions usually involve the en- 
tire body in sharp jerking movements, with 
blueness of the face or lips, complete loss of 
consciousness, and are usually followed by a 
period of sleep or drowsiness, and are frequently 
accompanied by frothing at the mouth, biting 
of the tongue, and occasionally by wetting or 
soiling of the clothes. 

Another class of convulsions is the hysterical, 
which are often difficult to distinguish. The 
hysterical convulsion, however, differs from the 
epileptic in the following respects. The hysteri- 
cal patient often shouts, cries or raves, not 
only previous to but frequently throughout the 
attack, and is often able to reply to questions 



23 



during' the convulsion. The epileptic gives a 
single cry, immediately followed by unconscious- 
ness and the spasm. The movements in the 
hysterical convulsion are often accompanied by 
bowing of the body backward, and very fre- 
quently simulate intentional or voluntary move- 
ments, such as tearing the hair, pulling at the 
clothes, and such things; while the epileptic 
movements are characterized by their jerking 
or twitching- character. The hysterical patient, 
also, in place of a convulsion, may strike an 
attitude, such as of fear or entreaty, often 
accompanied by raving or singing. This again 
may follow the convulsion, taking the place of, 
and strikingly contrasted with, the almost in- 
variable sleep of the epileptic, which is almost 
never seen in hysteria. Hysterical patients if 
they fall seldom injure themselves by the fall, 
as epileptics frequently do. Biting the tongue 
almost invariably indicates an epileptic seizure, 
as does wetting or soiling the clothes when it 
occurs. 

Cases of epilepsy, whether mild or severe, 
require treatment, and advice as to whether 
they should be removed from school. Many 
cases do not require to be withdrawn from 
school, and are benefited by its discipline. 

III. — Excessive nerve fatigue, which is 
shown by irritability or sleeplessness, may in- 
dicate a neurasthenic condition, that is, a threat- 
ened nervous breakdown. Such symptoms may 



24 



be due to irregular habits, want of proper 
sleep, lack of suitable food, poor hygienic con- 
ditions, or simply from the child being pushed 
in school beyond its physical or mental capacity. 

Excessive fear or morbid ideas, bashfulness, 
undue sensitiveness, causeless fits of crying, 
morbid introspection and suspiciousness may 
also be symptoms of a neurasthenic condition, 
and call for investigation, and for the teacher's 
sympathy and winning of the child's confidence, 
to prevent developments of a more serious 
nature. 

This nerve fatigue may result in a child being 
unable for the time being to keep up in its 
work in school. 

Forgetfulness, loss of interest in work and 
play, desire for solitude, untidiness in dress 
or person, and like changes of character, are 
sometimes incidental to the period of puberty. 

IV. — Mentally defective children in the pub- 
lic schools exhibit certain common character- 
istics. " The essential evidence of mental defect 
is that the child is persistently unable to profit 
by the ordinary methods of instruction, as shown 
by lack of progress or failure of promotion 
through lack of capacity. After one, two or 
three years in school, they are either not able 
to read at all, or they have a very small and 
scanty vocabulary. One of the most constant 
and striking peculiarities is the feebleness of 



25 



the power of voluntary attention. The child is 
unable to fix his attention upon any exercise or 
subject for any length of time. The moment 
his teacher's direction is withdrawn, his atten- 
tion ceases. 

These children are easily fatigued by mental 
effort, and lose interest quickly. They are not 
observant. They are often markedly backward 
in number work. The}'' are especially backward 
in any school exercise requiring judgment and 
reasoning power. They may excel in memory 
exercises. They usually associate and play with 
children younger than themselves. They have 
weak will-power. They are easily influenced 
and led by their associates. These children may 
be dull and listless, or restless and excitable. 
They are often wilful and disobedient, and li- 
able to attacks of stubbornness and bad temper. 
The typical " incorrigible " of the primary 
grades often is a mentally defective child of 
the excitable type. They are often destructive. 
They may be cruel to smaller children. They 
are often precocious sexually. They may have 
untidy personal habits. Certain cases with only 
slight intellectual defect show marked moral 
deficiency. 

The physical inferiority of these defective 
children is often plainly shown by the general 
appearance. There is generally some evidence 
of defect in the figure, face, attitudes or move- 



26 



merits. They seldom show the physical grace 
and charm of normal childhood. The teeth are 
apt to be discolored and to decay early. 

It is a most delicate and painful task to tell 
a parent that his child is mentally deficient. 
This duty should be performed with the great- 
est tact, kindness and sympathy. It would be 
a great misfortune for the school physician and 
teacher, as well as for the child, to designate 
a pupil as feeble-minded who was only tempo- 
rarily backward. 

Temporary backwardness in school work may 
be due to removable causes, such as defective 
vision, impaired hearing, adenoid growths in 
nose or throat, or as the result of unhappy 
home conditions, irregular habits, want of 
proper sleep, lack of suitable food, bad hy- 
gienic conditions, etc. Great care must always 
be used in order not to confound cases of per- 
manent mental deficiency with cases of tempo- 
rary backwardness in school work, due to the 
causes mentioned above, or those described under 
the head of excessive nervous fatigue. 

In some cases, where the existence of mental 
defect is in doubt, accurate information is usu- 
ally to be obtained in the early history of the 
child. The time of first " taking notice," the 
time of recognition of the mother, that of be- 
ginning to sit up, to creep, to stand, to walk 
and to talk should be learned. Marked delay 



27 



in development in these respects is usually found 
in all pronounced cases of mental deficiency. 

It may be found useful to require teachers to 
refer at stated intervals to the medical inspect- 
ors for examination all children who, without 
obvious cause, such as absence or ill health, show 
themselves unable to keep up in their school 
work, who are unable to fix their attention, or 
are incorrigible, — though it does not follow 
that all such cases have either physical or mental 
defects. 

School Hygiene. 

The school physician should notice the venti- 
lating, lighting* and heating of the rooms, and 
the location of the source of water supply with 
reference to possible pollution. In case pollu- 
tion of the water supply is suspected, applica- 
tion should be made to the State Board of 
Health for an examination of the water. The 
general cleanliness of the schoolroom is of im- 
portance, and the admission of sunlight when 
possible is desirable. 

The Closets. — The school physician, accom- 
panied by the janitor of the school, should in- 
spect the toilet rooms, to see if the floors are 
clean and dry, that the bowls of the closets are 
properly emptied and kept clean. (If out- 
houses are used, a large supply of earth will aid 
in keeping the place in a sanitary condition.) 



28 



A few simple directions as to the cleanliness of 
the room should be posted in the closets. 

Cups. — The use of one drinking cup for a 
number of children is to be condemned, as tend- 
ing to spread the infectious diseases from child 
to child. The so-called hygienic drinking foun- 
tain, now in more or less general use in pro- 
gressive cities and towns, is to be recommended 
where running water is available. If there is 
no running water, each child should use his own 
cup. 

School Furniture. 

Any proper sort of school furniture should 
furnish a seat of such height that the feet will 
rest easily on the floor. It should have a desk 
high enough not to touch the knees. It should 
have a desk low enough for the arm to rest on 
comfortably without much raising of the elbow; 
not, however, so low that the scholar must bend 
down to write on it. 

The seat should be near enough so that the 
scholar may reach the desk to write on it with- 
out leaning forward more than a little, and 
without entirely losing the support of the back- 
rest. The seat should not be so close as to press 
against the abdomen nor near enough to inter- 
fere with easy rising from the seat. This means 
a distance of ten and one-half to fourteen and 
one-half inches from the edge of the desk to the 
seat back; it also means that the seat must not 




BOSTON SCHOOL-DESK AND CHAIR. 




BOSTON SCHOOL-DESK AND CHAIR. 



29 



project under the desk more than an inch at 
most. 

The seat should have a back-rest that will 
support the " small of the back " properly, with- 
out having the scholar lean back excessively. 
Whether it also supports the rest of the back 
or not is of small consequence; support of the 
back carried up to the level of the shoulder 
blades is likely to do more harm than good. 

These are given as the minimum requirements. 
Whether or not regular adjustable furniture is 
in use, we should not be content with less than 
the accomplishment in one way or another of 
these primitive adjustments. More accurate ad- 
justment is desirable, and less care in adjusting 
would be hard to justify, in the light of our 
present knowledge of the results of faulty atti- 
tude. 

The furniture shown in the accompanying 
photograph conforms to these requirements. It 
was devised by physicians at the request of the 
Boston Schoolhouse Commission, and is adapted 
to the physiological requirements. The expense 
is no more than that of ordinary school furni- 
ture. It is for sale in the open market. In the 
Boston schools there are twenty-two thousand in 
use, and it is being adopted elsewhere. 



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